Provider Demographics
NPI:1588671978
Name:WILLIAMS, TINA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43151 DALCOMA DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6306
Mailing Address - Country:US
Mailing Address - Phone:586-286-8720
Mailing Address - Fax:586-649-6699
Practice Address - Street 1:2950 KEEWAHDIN RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3526
Practice Address - Country:US
Practice Address - Phone:810-455-1600
Practice Address - Fax:810-455-1620
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003406207N00000X
5601003406363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN81220002Medicare ID - Type Unspecified
MIP08907Medicare UPIN